Germinoma presenting as a fourth cranial nerve palsy in a patient with adenomatous polyposis coli (APC) gene mutation

A 17-year-old boy with adenomatous polyposis and a history of an adenomatous polyposis coli (APC) gene mutation (IVS13(-2) A>G) presented for evaluation of vertical, binocular diplopia. Examination was suggestive of a fourth (trochlear) nerve palsy. A history of headaches was elicited and led to further investigation with neuroimaging, which identified a germinoma in the tectal plate and secondary hydrocephalus. We report the clinical, radiological, and histopathological findings of this patient, who to our knowledge is the first reported case of a germinoma occurring in association with adenomatous polyposis.

Maternal hormone levels and risk of cryptorchism among populations at high and low risk of testicular germ cell tumors

Cryptorchism is one of the few well-described risk factors for testicular cancer. It has been suggested that both conditions are related to increased in utero estrogen exposure. The evidence supporting the "estrogen hypothesis" has been inconsistent, however. An alternative hypothesis suggests that higher in utero androgen exposure may protect against the development of cryptorchism and testicular cancer. In order to examine both hypotheses, we studied maternal hormone levels in two populations at diverse risks of testicular cancer; Black Americans (low-risk) and White Americans (high-risk). The study population of 200 mothers of cryptorchid sons and 200 mothers of noncryptorchid sons was nested within the Collaborative Perinatal Project, a cohort study of pregnant women and their children. Third trimester serum levels of estradiol (total, free, bioavailable), estriol, testosterone (total, free, bioavailable), sex hormone-binding globulin, alpha-fetoprotein, and the ratios of estradiols to testosterones were compared between the case and control mothers. The results found no significant differences in the levels of testosterone (total, free, bioavailable), alpha-fetoprotein, sex hormone-binding globulin, or in the ratios of estrogens to androgens. Total estradiol, however, was significantly lower in the cases versus the controls (P = 0.03) among all mothers and, separately, among White mothers (P = 0.05). Similarly, estriol was significantly lower among all cases (P = 0.05) and among White cases (P = 0.05). These results do not support either the estrogen or the androgen hypothesis. Rather, lower estrogens in case mothers may indicate that a placental defect increases the risk of cryptorchism and, possibly, testicular cancer.

Anterior mediastinal immature teratoma with precocious puberty in a child with Klinefelter syndrome

Klinefelter syndrome occurs in approximately 1 in 1000 males. A 4-year-old boy presented with precocious puberty and an anterior mediastinal mass. Serum alpha-fetoprotein and human chorionic gonadotropin levels were mildly increased. Computed tomography revealed a germ cell tumor (GCT) of the mediastinum. Complete resection of the tumor was performed. Histologic analysis revealed an immature teratoma. Males with Klinefelter syndrome develop GCTs at a rate 50 times higher than unaffected males. This case report calls attention to the need to rule out Klinefelter syndrome in boys who present with precocious puberty and a mediastinal GCT.

Carcinoma in situ testis, the progenitor of testicular germ cell tumours: a clinical review

Testicular germ cell tumours (TGCT), including seminomas, embryonal carcinomas, teratomas and yolk sac tumours, have a common precursor, the carcinoma in situ (CIS) cell. Recent gene expression studies displaying close similarity of CIS cells to embryonic stem cells support the longstanding theory that CIS most likely originates in utero from fetal gonocytes. The clinical association between the testicular dysgenesis syndrome components (TGCT, cryptorchidism, genital malformations, some forms of decreased spermatogenesis) also implies a prenatal origin. Despite high cure rates of TGCT, efforts should be made to obtain diagnosis at the CIS stage, as intervention is possible before an invasive tumour develops, thus reducing the necessity for intensive therapy. CIS may be suspected in patients with an assumed extragonadal GCT or cryptorchidism, and in intersex patients and selected cases with infertility (presenting with atrophic testes and ultrasonic microlithiasis). Surgical testicular biopsy seems the only reliable diagnostic method. The management of choice of unilateral CIS is orchidectomy, or localised irradiation in bilateral cases. At least 5% of TGCT patients present with contralateral CIS; therefore, contralateral biopsy is recommended at the time of orchidectomy. Further research is warranted to identify causal factors explaining the increasing incidence of TGCT and to obtain a method of non-invasive CIS detection.

Genetic alteration of poly(ADP-ribose) polymerase-1 in human germ cell tumors

Accumulated evidence suggests that poly(ADP-ribose) polymerase-1 (PARP-1) is involved in DNA repair, cell-death induction, differentiation and tumorigenesis. Parp-1 deficiency also induces trophoblast differentiation from mouse embryonic stem cells during teratocarcinoma-like tumor formation. To understand the relationship of PARP-1 dysfunction and development of germ cell tumors, we conducted a genetic analysis of the PARP-1 gene in human germ cell tumors. Sixteen surgical specimens of germ cell tumors that developed in the brain and testes were used. Two known single nucleotide polymorphisms (SNPs) (Val762Ala and Lys940Arg), which are listed in the SNP database of the NCBI (National Center for Biotechnology Information), were detected. In both cases, cSNPs encoded amino acids located within peptide stretches in the catalytic domain, which are highly conserved among various animal species. Furthermore, another novel sequence alteration, a base change of ATG to ACG, was identified in a tumor specimen, which would result in the amino acid substitution, Met129Thr. This base change was observed in one allele of both tumor and normal tissues, suggesting that it is either a rare SNP or a germline mutation of the PARP-1 gene. Notably, the amino acid Met129 is located within the second zinc finger domain, which is essential for DNA binding and is conserved among animal species. One SNP in intron 2 and one in the upstream 5'-UTR (untranslated region) were also detected.

Involvement of E-cadherin and beta-catenin in germ cell tumours and in normal male fetal germ cell development

Intercellular contacts, mediated by E-cadherin, are essential for germ cell migration and maturation. Furthermore, it has been suggested that decrease or loss of E-cadherin correlates with tumour progression and invasive behaviour. beta-catenin is involved in a number of different processes, including cell--cell interaction when bound to cadherins, and determination of cell fate in pluripotent cells when activated via the Wnt signal-transduction pathway. To shed more light on the role of these factors in normal fetal germ cell development and the pathogenesis of germ cell tumours (GCTs), the present study investigated the presence and localization of E-cadherin and beta-catenin by immunohistochemistry. E-cadherin was only weakly expressed in or absent from fetal germ cells of the second and third trimesters, and was not expressed in carcinoma in situ/intratubular germ cell neoplasia unclassified (CIS/ITGCNU) and gonadoblastoma, the precursor of an invasive GCT in dysgenetic gonads. In GCTs, it was generally not expressed in seminoma and dysgerminoma, but was found in the vast majority of non-seminoma cells. beta-catenin was found in the cytoplasm of fetal germ cells at all gestational ages and in spermatogenesis in post-pubertal testes. It was also present in CIS/ITGCNU and gonadoblastoma. Whereas seminomas and dysgerminoma were negative, non-seminoma cells were frequently found to express beta-catenin. Expression of both factors therefore reflects the degree of differentiation of these tumours. No differences for either E-cadherin or beta-catenin were observed between samples of tumours resistant or sensitive to chemotherapy, and E-cadherin expression did not correlate with vascular invasion. E-cadherin and beta-catenin therefore play a role in both normal and malignant germ cell development and differentiation that warrants further investigation, but they seem to be of limited value as predictive or prognostic factors in GCTs.

Risk factors in past histories and familial episodes related to development of testicular germ cell tumor

BACKGROUND

A retrospective study was conducted to examine the host factors of 240 testicular germ cell tumor patients. This study was performed to address a new theory proposed by Skakkebaek called testicular dysgenesis syndrome which claims that cryptorchism, hypospadias, poor semen quality and testicular germ cell tumors are symptoms of an underlying testicular dysgenesis in uterus.

METHODS

The past health histories and familial episodes of 240 testicular germ cell tumor patients were examined. The past health histories included cryptorchism, hypospadias, infertility, atrophic testis and inguinal hernia.

RESULTS

Of the 240 patients, 13 (5.4%) had a history of cryptorchism or orchidopexy. Two (0.8%) showed existence of hypospadias or had experienced urethroplasty. Among 129 married couples, 104 (80.6%) couples were fertile. Three (1.3%) patients developed testicular tumors after they were diagnosed as infertile or came to the hospital with the complaints of infertility. Four (1.7%) had contralateral atrophic testis. 19 (7.9%) had experienced inguinal herniorrhaphy before age 15. Three (1.3%) had testicular germ cell tumor patients among their family or relatives.

CONCLUSIONS

The testicular germ cell tumor patients showed a considerable incidence of complications such as cryptorchism, hypospadias and incomplete closure of processus vaginalis. Cryptorchism, perinatal factors and familial factors could be risks for developing testicular germ cell tumors.

Risk of childhood germ cell tumors in association with parental smoking and drinking

BACKGROUND

The etiology of childhood germ cell tumors (GCT) is not well understood. The Children's Oncology Group conducted the largest case-control study of childhood GCT to investigate whether parental exposures to smoking and alcohol contributed to the disease.

METHODS

Cases included 274 children with GCT diagnosed between January 1, 1993 and December 31, 2001 who were age <15 years. Controls (n=421) were selected by random digit dialing and were frequency matched based on gender, age (+/-1 year), and geographic area. Exposure information was collected from subjects' parents using independent telephone interviews and self-administrated questionnaires.

RESULTS

No association was found between parental smoking or drinking alcohol and risk of childhood GCT (for smoking: odds ratio [OR]=1.0, 95% confidence interval [95% CI], 0.8-1.3 and OR = 1.2, 95% CI, 0.9-1.5, for mothers and fathers, respectively; for drinking: OR=0.9, 95% CI, 0.7-1.2 and OR=1.0, 95% CI, 0.8-1.3, for mothers and fathers, respectively). No significant trend was observed for length of maternal exposure to passive smoking during the index pregnancy and GCT risk (for total subject: P=0.77; boys: P=0.52; girls: P=0.93).

CONCLUSIONS

The authors found no evidence that childhood GCT was related to prenatal exposure to parental cigarette smoking, alcohol drinking, and maternal passive smoking.

Transcription Factor AP-2γ Is a Developmentally Regulated Marker of Testicular CarcinomaIn situand Germ Cell Tumors

PURPOSE

Transcription factor activator protein-2gamma (TFAP2C, AP-2gamma) was reported previously in extraembryonic ectoderm and breast carcinomas but not in the testis. In our recent gene expression study we detected AP-2gamma in carcinoma in situ testis (CIS, or intratubular germ cell neoplasia), precursor of testicular germ cell tumors. In this study we aimed to investigate the expression pattern of AP-2gamma and to shed light on this factor in germ cell differentiation and the pathogenesis of germ cell neoplasia.

EXPERIMENTAL DESIGN

We analyzed expression pattern of AP-2gamma at the RNA and protein level in normal human tissues and a panel of tumors and tumor-derived cell lines. In the gonads, we established the ontogeny of expression of AP-2gamma in normal and dysgenetic samples. We also investigated the regulation of AP-2gamma by steroids and retinoic acid.

RESULTS

We detected abundant AP-2gamma in testicular CIS and in testicular germ cell tumors of young adults and confirmed differential expression of AP-2gamma in somatic tumors. We found that AP-2gamma expression was regulated by retinoic acid in an embryonal carcinoma cell line (NT2). The investigation of ontogeny of AP-2gamma protein expression in fetal gonads revealed that it was confined to oogonia/gonocytes and was down-regulated with germ cell differentiation. In some prepubertal intersex cases, AP-2gamma was detected outside of the normal window of expression, probably marking neoplastic transformation of germ cells.

CONCLUSIONS

AP-2gamma is developmentally regulated and associated with the undifferentiated phenotype in germ cells. This transcription factor may be involved in self-renewal and survival of immature germ cells and tissue-specific stem cells. AP-2gamma is a novel marker of testicular CIS and CIS-derived tumors.

The frequency of intratubular embryonal carcinoma: implications for the pathogenesis of germ cell tumours

AIMS

To define the frequency and distribution of intratubular embryonal carcinoma (IEC) in an attempt to shed light on the pathogenesis of non-seminomatous germ cell tumours (NSGCTs). Intratubular germ cell neoplasia of unclassified type (IGCNU) is common in NSGCT; however, IEC is rarely described.

METHODS AND RESULTS

Sixty-two germ cell tumours were reviewed. Immunochemistry for CD30, placental alkaline phosphatase (PLAP) and c-kit was performed. The distribution, immunohistochemistry and morphology of the intratubular neoplasia were noted. All cases showed widespread IGCNU with PLAP and c-kit staining. CD30 showed strong focal intratubular positivity in 20/31 NSGCTs, 1/29 seminomas and 1/4 mixed seminomas/NSGCTs. In 17 of these cases, the CD30+ tubules were not easily identified as IEC on routine stains. These tubules were scanty in number and c-kit was negative, though some showed patchy PLAP staining. The cells within these tubules differed morphologically from IGCNU.

CONCLUSIONS

IEC defined by CD30 positivity is not always easily identified on haematoxylin and eosin staining. We suggest that IEC is a common intermediate step between IGCNU and NSGCTs. The patchy and focal distribution of IEC suggests it may evolve quickly to invasive disease.

Neonatal liver tumours

Primary liver tumours are very rare during the neonatal period, but increasing numbers of them are now diagnosed prenatally by routine ultrasound scan. A precise diagnosis is sometimes problematic because of non-specific clinical symptoms, misleading imaging and difficulties with histological interpretation. Benign infantile haemangioendothelioma usually undergoes spontaneous regression, but may be life-threatening due to congestive heart failure and/or consumptive coagulopathy when treatment with resection, embolization or arterial ligation is necessary. Malignant hepatoblastoma may occur in the newborn, and often has to be treated with chemotherapy to achieve resectability. Symptoms are less specific and the prognosis is worse than in older children. Mesenchymal hamartoma is a benign cystic lesion that should be resected whenever possible. Rarely, germ cell tumours occur in the neonatal liver. Benign teratomas have to be resected, while malignant choriocarcinomas may respond to chemotherapy and can be cured in some cases.

De novo germinoma in the brain in association with Klinefelter's syndrome: case report and review of the literature

BACKGROUND

There are no previous reports about de novo germ cell tumors without any past history of germ cell tumor. We describe a case of de novo cerebral germinoma in association with Klinefelter's syndrome.

CASE DESCRIPTION

A boy had undergone growth hormone therapy for dwarfism because of hypopituitarism from 10 to 17 years old. The result of karyotyping at the age of 13 was 47,XXY. Magnetic resonance images (MRI) of the brain at the age of 17 years showed no lesions. Two years later, at the age of 19, the patient noticed onset of mild right hemiparesis. MR imaging revealed the existence of a brain tumor in the left temporal lobe and hypothalamus. The patient underwent an operation and the histologic diagnosis of the lesion was germinoma. After postoperative chemotherapy and radiation therapy, the lesion disappeared and the patient was discharged uneventfully.

CONCLUSIONS

To the best of the authors' knowledge, this is the first reported case of a germ cell tumor to be de novo without any past history of other germ cell tumor and the seventh case in which it occurred in association with Klinefelter's syndrome.

Clinical review of 55 cases of malignant ovarian germ cell tumors

PURPOSE OF INVESTIGATION

A retrospective analysis of 55 cases of malignant germ cell tumors in a 20-year period was done to evaluate the impact of conservative surgery and adjuvant treatment on survival and fertility.

METHODS

Fifty-five cases of malignant ovarian germ cell tumors (MOGCTs) were studied. Mean age was 22 years. Dysgerminoma was the most common histotype (45%).

RESULTS

Thirty-nine patients (71%) presented with FIGO surgical Stage I disease. Fertility-sparing surgery was performed in 39 (71%) women. Postoperative systemic chemotherapy was administered to 40 women (73%), 27 (68%) had received conservative treatment. One woman developed renal failure after the first cycle of chemotherapy and died a few days thereafter and there was one case of bleomycin-induced death due to pulmonary fibrosis. There were eight (14.5%) clinical recurrences. Overall survival rate for relapsing women was 75% (6/8). The recurrence rate for women treated conservatively was 15%, and it was 13% for those treated radically. With a median follow-up of 129 months the overall survival rate for the entire study-population was 90.9%. Eleven pregnancies occurred in 36 women treated with fertility-sparing surgery who were of child-bearing age.

CONCLUSION

The management of MOGCTs with fertility-sparing surgery is a safe, practicable treatment option. The majority of these patients can retain normal ovarian function and reproductive potential after chemotherapy treatment.

Multipoint methylation analysis indicates a distinctive epigenetic phenotype among testicular germ cell tumors and testicular malignant lymphomas

Hypermethylation of tumor-suppressor genes has been implicated in the pathogenesis of human cancers. Although a growing number of genes showing hypermethylation is being reported in human cancer, methylation profiles of tumor-related genes in testicular neoplasms have not been well elucidated. This study was designed to show the methylation profiles of multiple CpG islands in testicular germ cell tumors (TGCTs) in comparison with those in testicular malignant lymphomas. We studied the methylation status of E-cadherin, CDKN2B, CDKN2A, BRCA1, RB1, VHL, RASSF1A, RARB, and GSTP1 by use of TGCT tissues and testicular malignant lymphoma tissues (25 primary TGCT tissues and three primary testicular lymphoma tissues). Methylation was not observed in E-cadherin, CDKN2B, CDKN2A, BRCA1, RB1, VHL, RASSF1A, RARB, and GSTP1 in any of the TGCT tissues. In contrast, all three (100%) of the testicular lymphoma tissues demonstrated hypermethylation of E-cadherin, RASSF1A, and RARB, but not CDKN2B, CDKN2A, BRCA1, RB1, VHL, and GSTP1. These data demonstrate that a distinctive epigenetic phenotype underlies the TGCTs and testicular lymphomas at the CpG sites of E-cadherin, RASSF1A, and RARB; a distinctive epigenetic phenotype was not observed among seminomatous TGCTs and non-seminomatous TGCTs at the CpG sites examined.

Adult primary extragonadal germ cell tumors: Treatment results and long-term follow-up

BACKGROUND

Primary extragonadal germ cell tumors (PEGCT) are rare neoplasms. They have a poor prognosis, different behavior, and natural course compared to their gonadal counterparts. Both primary and salvage treatment of these tumors constitute a challenge. We retrospectively evaluated the clinicopathologic status, therapeutic implications, and outcome of our patients with PEGCT.

PROCEDURE

Between 1991 and 2000, 18 patients with PEGCT (median age 31 years; range 17-63), diagnosed with tru-cut biopsy and treated with cisplatin-based chemotherapy, were evaluated in respect to treatment response and outcome.

RESULTS

Cisplatin-based chemotherapy achieved a complete response rate of 27.8% and a partial response rate of 55.5%. Overall response rate was 83.3%. Only three patients were unresponsive to chemotherapy; an additional six patients with residual mass underwent surgical resection and were rendered disease-free by surgery. The 5-year actuarial event-free and overall survival were 63.4 and 71.3%, respectively.

CONCLUSIONS

The outcomes of our patients with extragonadal primaries including mediastinal localization appear to be slightly better than those previously reported. Multimodality therapy is essential for these patients and given the relatively poor prognosis, prospective trials with large sample sizes, and new treatment approaches to improve outcome are required.

A case-control study of dietary phytoestrogens and testicular cancer risk

A few dietary studies have found elevated testicular cancer risks for higher red meat, fat, and milk intakes and lower intakes of fruits, vegetables, and fiber. Because hormonal modulation by dietary intake of plant estrogens could affect risk of testicular cancer, we chose to explore the possible relationship between dietary phytoestrogens and testicular cancer. We conducted a hospital-based case-control study of 159 testicular cancer cases diagnosed between 1990 and 1996 and 136 adult friend-matched controls at the University of Texas M. D. Anderson Cancer Center. Amounts of phytoestrogenic compounds in foods were added to the National Cancer Institute's DietSys program and then grouped into prelignans, lignans, flavonoids, isoflavonoids, phytosterols, and coumestrol for statistical analysis, expressed per 1,000 kcal. The results of multivariate logistic regression analysis showed, after adjustment for age, education, income, ethnicity, cryptorchidism, body mass index, baldness unrelated to therapy, severe acne in adolescence, early puberty, daily fiber and fat intake, and total daily calories, no discernable monotonic increased or decreased risk estimates across quartiles of phytoestrogen intake. A U-shaped pattern was observed for lignans and coumestrol. Further evaluation of this pattern by cubic spline parameterization did fit the data, but the data were also consistent with no effect. This hypothesis-generating study does not support the premise that dietary phytoestrogens increase or decrease testicular cancer risk in young men.

[Non-AIDS-related malignancies: prognostic and treatment]

Malignant tumors currently rank among the leading cause of morbidity and mortality in patients infected with HIV. The survival is increased for patients who benefits from better control of viral replication and from progress in prevention of opportunistic infections. These patients are thus exposed to an increased risk of cancer. The most frequent malignant tumors not associated with AIDS stage are Hodgkin disease, germ-cell tumors, cutaneous cancer, head and neck cancer and lung cancer. The goal of this chapter is to describe the clinical and histological pattern of these malignant tumors, and to propose therapeutic guidelines for HIV patients with cancer.

Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial

PURPOSE

To prospectively assess potential risk factors for relapse in clinical stage I nonseminomatous germ cell tumors of the testis (CS I NSGCT).

PATIENTS AND METHODS

From September 1996 to May 2002, 200 patients with CS I NSGCT were prospectively assigned to retroperitoneal lymph node dissection (RPLND), and risk factor assessment was performed within a multicenter protocol. One hundred sixty-five patients had an adequate minimum follow-up of 12 months (mean, 34.5 months) or had pathologic stage II.

RESULTS

Pathologic stage II disease was found in 27.9% of patients. Only 0.6% of patients relapsed in the retroperitoneum after confirmation of pathologic stage I disease. With reference pathology, vascular invasion (VI) was most predictive of stage in multifactorial analysis (accuracy, 65.1%). However, the positive predictive value (PPV) of VI to predict patients who have metastatic disease or relapse during follow-up was only 52.7%. With absent VI, low-risk patients had a negative predictive value (NPV) of 76.9%. With a combination of several risk factors, the PPV increased to 63.6% and the negative predictive value increased to 86.5%.

CONCLUSION

Even with an optimal combination of prognostic factors and reference pathology, more than one third of patients predicted to have pathologic stage II or relapse during follow-up will not harbor metastatic disease and, therefore, would be overtreated with adjuvant therapy. However, patients at low risk may be predicted at an 86.5% level, and thus, surveillance in highly compliant patients would be a valuable option. For high-risk patients, further reduction of adjuvant treatment is necessary.

Deregulation of the G1/S-phase control in human testicular germ cell tumours

Deregulated cell cycle and defective genome-integrity checkpoints are among the hallmarks of cancer. Here we summarize our recent studies of key components of the GI/S machinery in normal human spermatogenesis, and their abnormalities in testicular germ cell tumours (TGCTs), with special emphasis on carcinoma in situ lesions (CIS). Our combined immunohistochemical and immunoblotting analyses of normal human adult and fetal testes, CIS, seminomas, embryonal carcinomas, and teratomas, revealed an 'unorthodox' spectrum of defects within the so-called RB pathway in TGCTs. The early aberrations included lack of expression of the retinoblastoma tumour suppressor (pRB) and the CDK inhibitor pl9ink4d, and overexpression of cyclin D2. Progression from CIS to invasive TGCTswas associated with loss of another two CDK inhibitors and tumour suppressors: pl6ink4a and pl8ink4c. We also found the lack of pRB and pl9ink4d in fetal gonocytes, the candidate target cell for all types of TGCTs. These findings, together with the status of the Chk2-p53 DNA-integrity checkpoint, are considered in relation to the origin, biology and pathogenesis of TGCTs, and potential implications of the GI/S defects for the curability of these tumours.

Current views on the pathogenesis of testicular germ cell tumours and perspectives for future research: highlights of the 5th Copenhagen Workshop on Carcinoma in situ and Cancer of the Testis

This review article highlights the most important contributions presented at the 5th Copenhagen Workshop on Carcinoma in situ and Cancer of the Testis, which was held in Denmark, August 29-31, 2002. The major themes that emerged at the meeting are critically discussed and perspectives for future research in this field are presented.

Malignant ovarian germ cell tumors: analysis of 32 cases

OBJECTIVE

In this study, some clinicopathologic characteristics and the outcome of patients with malignant ovarian germ cell tumors (MOGCT) were evaluated.

MATERIALS AND METHODS

The clinical charts and pathologic reports of 32 patients with MOGCT treated at the Department of Obstetrics and Gynecology, and diagnosed at the Department of Pathology, Medical Faculty of Dicle University, Turkey from 1983 to 1999 were reviewed.

RESULTS

Thirteen patients (40.6%) had dysgerminoma, nine (28.1%) had immature teratoma (four grade 1, three grade 2, and two grade 3), eight (25%) had endodermal sinus tumor, and two (6.3%) patients had mixed germ cell tumors. Site of involvement was unilateral in 30 (19 on the right and 11 on the left) and bilateral in two. All patients underwent primary surgery and 26 patients combination chemotherapy. There seemed to be a relationship between pathologic findings and clinical outcome, and MOGCT histologic types may affect the prognosis.

CONCLUSION

Dysgerminoma had a better prognosis than the nondysgerminomatous group (p < 0.05). This study provides additional data in confirmation of previous reports that management of MOGCT with fertility preservation is safe.

Malignant ovarian germ cell tumors: the KK Hospital experience

Ovarian germ cell malignancies pose a therapeutic challenge especially amongst young patients. This is a retrospective review of 49 patients treated for such malignancies at KK Women's and Children's Hospital over a 13-year period. The relative proportion of such tumors was 6.2%. Age at presentation ranged from 14 to 51 years (mean 25.4 years). Forty-nine percent of tumors were immature teratomas and 81.6% had stage I disease. All patients had surgery initially and 67.3% required postoperative adjuvant chemotherapy. The patients were followed-up for one to 145 months (mean 51.6 months). All the 87.8% of patients on follow-up are alive and disease-free. There was one recurrence. Five patients had eight successful pregnancies, with no congenital anomalies. Mean duration when menstruation was resumed and regular was 2.5 and 3.5 months, respectively. With combination chemotherapy and conservative surgery, the outlook for patients is excellent, with emphasis on preservation of ovarian function and fertility.

Important factors in the diagnosis and primary staging of testicular tumours

PURPOSE OF REVIEW

In the present review we outline the use of different staging methods and highlight future possibilities in the management of testicular germ cell cancer.

RECENT FINDINGS

The 5-year survival for testicular cancer has improved dramatically over the past 30 years, with cure rates approaching 95%. This success is attributed to the appropriate integration of effective treatments and staging modalities. Staging currently represents the cornerstone on which treatment is based. Because most patients will be cured, attention has shifted toward reducing morbidity of treatment while maintaining high cure rates. This implies that staging must be accurate before any change to the treatment regimen can be instituted.

SUMMARY

Effective management of testicular germ cell cancer continues to pose a major challenge. Early and accurate diagnosis is very important because it will influence the choice of treatment and thus may impact on prognosis.

How valid is the prenatal estrogen excess hypothesis of testicular germ cell cancer? A case control study on hormone-related factors

PURPOSE/AIMS

The prenatal estrogen excess hypothesis postulates abnormally high estrogen levels during pregnancy which predispose the developing gonad to testicular germ cell cancer (GCT) in adulthood. As no direct measurements are possible to support this hypothesis, evidence must come from clinical and epidemiological observations. The present study looked to surrogate parameters that purportedly point to high estrogenic influence in utero.

METHODS/PATIENTS

In a case-control study design, 418 cases with GCT were compared to 636 controls having fractures, injuries or nephrolithiasis. A second comparison was done with 120 men suffering from malignant melanoma. The following factors were investigated: maternal and paternal age at birth of proband, birth-order, distribution of brothers and sisters in sibs of patients, sibship size, status of being a twin, status of being a singleton child, handedness, and frequency of breast cancer in mothers and sisters.

RESULTS

Status of being a twin was significantly associated with GCT risk (OR 2.41; 95% CI 1.04- 5.63) if compared to men with fractures or stones. Comparison with melanoma controls showed only a nonsignificant trend. Frequency of breast cancer was insignificantly higher in mothers of GCT patients. Maternal age above 30 years was associated with decreased risk of GCT, which is contradictory to the hypothesis. No other parameter was significantly different in cases and controls.

CONCLUSION

The present investigation failed to produce evidence for the estrogen excess hypothesis. Obviously, the parameters tested are only weak indicators of estrogenic influence during embryogenesis. Thus, the sample size and statistical power of the trial might have been too low to show any significant association. But, assessing the negative results of this study in light of equally negative results in previous investigations, the estrogen excess hypothesis still remains to be hypothetic.

[A prospect of molecular biology in the field of urologic oncology: mechanisms of carcinogenesis or tumor development in testicular cancer]

Testicular germ cell tumor comprises about 1% of all the malignancies of males in Japan, and occurs in only one over 100,000 males annually. A susceptibility gene may be located on the short arm of the chromosome 12. Among the genes in this region, the expression of the KRAS2 mRNA was increased in testicular cancer compared to the normal testicular tissue. By DNA typing, HLA-DR4 and 0405 allele in HLA-DRB1 showed high relative risk for testicular cancer. We analyzed the expression of the WT1 gene, reported to be a growth promoter for leukemia, by quantitative reverse transcription-PCR. Relative expression of the WT1 gene was significantly increased in high-stage cases than in low-stage cases, suggesting that WT1 could be useful as a tumor marker for progression of testicular cancers. Testicular germ cell tumors are usually very sensitive to chemotherapeutic agents such as cisplatin, and p53 has been reported to play an important role in chemosensitivity. Therefore, mutations of the p53 gene or other genes downstream may be responsible for their chemoresistance. The expression of the GML (GPI--anchored molecule like protein) gene was examined in testicular cancers. Its expression was not correlated with histology or stage. However, 4 refractory cases, 2 of which were recurrent cases from stage I and the others were at high stages, showed no expression of the GML mRNA. These interesting facts suggest that the expression of GML gene could be a good marker for the prognosis of testicular germ cell tumors.

Incidence of testicular cancer and occupation among Swedish men gainfully employed in 1970

PURPOSE

To estimate occupation-specific risk of seminomas and nonseminoma subtypes of testicular cancer among Swedish men gainfully employed in 1970 over the period 1971-1989.

METHODS

Age-period standardized incidence ratios were computed in a dataset linking cancer diagnoses from the Swedish national cancer register to occupational and demographical data obtained in the census in 1970. Log-linear Poisson models were fitted, allowing for geographical area and town size. Taking occupational sector as a proxy for socioeconomic status, occupational risks were recalculated using intra-sector analyses, where the reference group comprised other occupations in the same sector only. Risk estimators per occupation were also computed for men reporting the same occupation in 1960 and 1970, a more specifically exposed group.

RESULTS

Seminomas and nonseminomas showed a substantial geographical variation. The association between germ-cell testicular tumors and high socioeconomic groups was found mainly for nonseminomas. Positive associations with particular occupations were more evident for seminomas, for which railway stationmasters, metal annealers and temperers, precision toolmakers, watchmakers, construction smiths, and typographers and lithographers exhibited a risk excess. Concrete and construction worker was the only occupation consistently associated with nonseminomas.

CONCLUSIONS

Among the many occupations studied, our results corroborate the previously reported increased risk among metal workers, specifically related with seminomatous tumors in this study. Our results confirm the geographical and socioeconomical differences in the incidence of testicular tumors. These factors should be accounted for in occupational studies. The different pattern of occupations related with seminomas and nonseminomas support the need to study these tumors separately.

Cryptorchidism: aspects of fertility and neoplasms. A study including data of 1,335 consecutive boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism

PURPOSE

An attempt to make a rational strategy for treatment of cryptorchidism.

MATERIALS AND METHODS

1,335 cryptorchid boys with biopsy at surgery (1,638 specimens). We studied: frequency of no germ cells in biopsies from 698 patients <12 years at surgery; fertility potential of 140 patients who were now adults, and apperance of testicular neoplasia in all biopsies.

RESULTS

Lack of germ cells appeared from 18 months. The frequency increased with increasing age. It appeared in 30% (61/202) bilateral, and 18% (88/496) unilateral cases. In men who had undergone bilateral or unilateral orchiopexy, respectively, there was normal sperm count in 19% (14/75) and 83% (54/65), and infertility was suspected in 56% (42/75) and 8% (5/65) (FE, p < 0.00005, p < 0.00005), respectively. The lowest, the mean, and the highest age-matched spermatogonia count per tubule at orchiopexy was associated with sperm count (Spearman test, p < 0.0001, p < 0.005, p < 0.05). Isolated, this was demonstrated for the 75 formerly bilateral (Spearman, p < 0.0001, p < 0.0001, p < 0.0001), but not the 65 formerly unilateral cases (Spearman, p = 1.0). No germ cells at orchiopexy was associated with suspected infertility. Risk was 78-100% in bilateral (dependent on one or both testes affected), and 33% in unilateral cryptorchidism. There was one invasive germ cell tumor, six cases of carcinoma in situ testis, and one Sertoli cell tumor. Three neoplasms were diagnosed in intra-abdominal testes, four in boys with abnormal external genitalia, and two in boys with known abnormal karyotype. Risk of neoplasia was 5% (7/150) in patients with intra-abdominal testis, abnormal external genitalia or diagnosed abnormal karyotype, versus 0% (0/1,185) in patients without these characteristics (FE, p < 0.00005).

CONCLUSION

We recommend surgery for cryptorchidism before 15-18 months of age because: (a) lack of germ cells is very rare before, and (b) lack of germ cells is associated with subsequent risk of infertility. At primary surgery for cryptorchidism, we recommend examination for testicular neoplasia in cases of intra-abdominal testis, abnormal external genitalia or known abnormal karyotype.

[Treatment of germ cell tumors at the threshold of the third millennium]

The aim of the authors is to present the risk factors and the risk factors based treatment strategy of germ cell tumors. They review the risk adapted treatment strategy of germ cell tumors using the treatment policy of the Léon Bérard Oncological Center and the current findings published. More than of 80% germ cell tumors may be cured by standard treatment. The treatment of stage I seminoma is lumboaortic radiotherapy and that of stage I non seminoma is either surveillance, retroperitoneal lymph node dissection or chemotherapy depending on the risk factors of extratesticular involvement (pure embryonal carcinoma, vascular invasion). The treatment of metastatic cases is chemotherapy: three cycles of bleomycin, etoposid, cisplatin of four cycles of the similar components without bleomycin for good risk patients, and four cycles bleomycin, etoposid and cisplatin in poor risk cases. The overall five year survival rates are 90 and 50% in cases of good and poor prognosis groups respectively. The indication of retroperitoneal lymph node dissection depends on the size of retroperitoneal spreading prior to chemotherapy and on the efficacy of chemotherapy. The second line salvage treatment is four cycles of a combination of vinblastin, ifosfamide and cisplatin. After salvage chemotherapy the resection of all residual masses is recommended. New drugs, such as gemcitabine, taxotere, oxaliplatin and high dose chemotherapy may bring further success, however these new treatment modalities are not available for clinical practice in Hungary. Risk adapted treatment for germ cell tumors decreasing the early and late toxicity's of conventional treatment may improve the patients quality of life, and may decrease the cost of standard treatment in Hungary. The said new medication and the use of high dose chemotherapy may further improve the chances of patients with poor and intermediate prognosis and of those who are resistant to the cisplatin based standard therapy.

Sorting the hype from the facts in testicular cancer: is testicular cancer related to trauma?

PURPOSE

The rate of testicular cancer is increasing. Trauma severe enough to cause testicular atrophy is a putative risk factor for testicular cancer but the epidemiological evidence is not conclusive. A population based, multicenter case-control study was performed from 1995 to 1997 to investigate potential risk factors for gonadal and extragonadal germ cell cancer.

MATERIALS AND METHODS

The study was done in 5 German regions. Interviews were performed with 269 eligible male patients with a histologically verified diagnosis and 797 controls. Detailed information on medical and family history was collected at personal interviews.

RESULTS

We identified a significantly elevated risk for testicular cancer in relation to testis and/or groin trauma (odds ratio 2.5, 95% confidence interval [CI] 1.51 to 4.20). After introducing a lag time by excluding reports of trauma within the last 12 months before diagnosis or interview the corresponding odds ratio was 2.1 (95% CI 1.24 to 3.61). Analysis of the circumstances and the reported types of injury allowed us to restrict the study to testis trauma specifically, which had an odds ratio of 3.49 (95% CI 1.78 to 6.81). To account for a potential reporting bias analysis was restricted to traumatic episodes for which medical attention was sought. This restriction resulted in an odds ratio of 0.70 (95% CI 0.19 to 2.63) after excluding from study trauma reports within the last 12 months.

CONCLUSIONS

The results of our study do not support the hypothesis that testicular trauma is an important risk factor for testicular cancer. The possibility of recall bias should be considered.

Pre-natal and peri-natal exposures and risk of testicular germ-cell cancer

The present case-control study was undertaken to investigate the association between exposure to maternal hormones and risk of testicular germ-cell cancer by histologic subgroups. Cases were males, aged 16 to 59 years, diagnosed with testicular germ-cell cancer in Ontario between 1987 and 1989. Histologic review was performed on all eligible cases for the purpose of categorizing cases as seminoma or non-seminoma (the latter classified 2 ways, with and without tumors containing seminoma). Risk factor data were collected on 502 cases, 346 case mothers, 975 age-matched controls, and 522 control mothers. Exogenous hormone exposure was associated with elevated risk (OR = 4.9, 95% CI 1.7-13.9). Several additional risk factors were associated with risk of testicular cancer: bleeding and threatened miscarriage (OR = 0.6, 95% CI 0.3-1.0), maternal cigarette smoking (12+ cigarettes/day OR = 0.6, 95% CI 0. 4-1.0). pre-term birth (OR = 1.6, 95% CI 1.0-2.5), and treatment for undescended testicle (OR = 8.0, 95% CI 3.2-20.0). First births were associated with elevated risk (OR = 1.7, 95% CI 1.0-2.8) among mothers below the age of 24 years at conception. There was little evidence that risk factors differed by histologic subgroup. We found evidence that exposure to maternal hormones, particularly estrogens, is associated with testicular germ-cell cancer risk. Not only does exposure to elevated levels (exogenous hormone use, pre-term birth, and first births among young mothers) increase risk but also exposure to relatively lower levels (heavy cigarette consumption and, perhaps, bleeding and threatened miscarriage) may decrease cancer risk.

Primary spinal germinoma in a patient with concomitant Klinefelter's syndrome

It is known that patients with Klinefelter's syndrome are inclined to develop concomitant malignant tumours, as well as extragonadal germ cell tumours. The association of a primary spinal germinoma in a patient with Klinefelter's syndrome is reported for the first time, and the coincidence of elevated gonadotropin levels and oncogenesis is discussed.

Diagnosis and treatment of patients with testicular germ cell cancer

Testicular germ cell tumours are a highly curable malignancy even in the presence of metastases, with an overall survival rate of approximately 90 to 95% when all stages are considered. Current therapeutic strategies aim at risk-adapted therapy, trying to maintain favourable overall results while reducing treatment-related toxicity, particularly in non-advanced disease. In stage I disease, unilateral inguinal orchiectomy represents the standard diagnostic and therapeutic approach. For patients with clinical stage I seminoma, prophylactic para-aortic radiotherapy with 26Gy is commonly employed. In patients with nonseminomatous germ cell tumours (NSGCT) at clinical stage I, the 3 options are: (i) retroperitoneal lymphadenectomy; (ii) a wait-and-see strategy; or (iii) 2 cycles of adjuvant chemotherapy. The individual risk profile for tumour recurrence, mainly based on histopathological criteria such as vascular tumour invasion, should guide treatment decisions in this group of patients. Radiotherapy is still the standard approach in clinical stage IIA/B seminoma, whereas in patients with a low tumour burden of NSGCT, retroperitoneal lymphadenectomy is frequently used followed by surveillance or adjuvant chemotherapy. Primary chemotherapy in these stages of disease may be at least equally successful. Major progress has also been achieved in the treatment of NSGCT patients with metastatic disease greater than clinical stage IIB, for whom primary chemotherapy represents the standard approach. After cisplatin-based combination chemotherapy, between 70 and 90% of patients will achieve a durable remission. In patients with 'good risk' metastatic disease, 3 cycles of cisplatin, etoposide and bleomycin (PEB) remain the standard treatment, despite several randomised trials trying to avoid the lung-toxic bleomycin or substituting cisplatin by carboplatin. In patients with 'intermediate' and 'poor prognosis' disease, 4 cycles of PEB given at 3-week intervals are considered routine treatment. The role of high dose chemotherapy with peripheral autologous blood stem cell transplantation is currently being investigated for patients presenting initially with advanced (poor prognosis) metastatic disease and for patients with relapse after previous chemotherapy, in whom conventional-dose salvage regimens will only result in 20% long-term survival. Because of the large group of patients with metastatic disease being cured, the possible long-term adverse effects of treatment have become important. Only a slightly elevated risk for therapy-related secondary malignancies has been identified. Long-term adverse effects associated with cisplatin may affect a larger proportion of patients. Further research should focus on reducing the risk of chemotherapy-related chronic toxicity.

Intracranial germ cell tumors in children with and without Down syndrome

PURPOSE

Two Chinese children with Down syndrome affected by intracranial germ cell tumors are described. Because they represent two of eight affected patients in the current series from 1990 to 1996, it is postulated that such occurrence may be more than a coincidental event.

PATIENTS AND METHODS

Two children with Down syndrome developed germ cell tumors in atypical intracranial sites that affected basal ganglion and cerebellum. The pathology showed germinoma and yolk sac tumor, respectively. These were treated by radical surgical resection and chemotherapy with cisplatin, etoposide, and bleomycin, but without radiotherapy.

RESULTS

One patient survived 3 years without radiologic evidence of tumor. The other died from infective complications caused by severe myelosuppression after chemotherapy.

CONCLUSIONS

Subtle neurologic manifestations in developmentally handicapped patients with intracranial space-occupying lesions could result in delayed diagnosis. Children with Down syndrome suffering from brain tumors may have a higher chance for germ cell tumors. Assay for alpha-fetoprotein and beta-human chorionic gonadotrophin could hasten diagnosis in some cases. This observation and review of literature suggest an increased risk of developing intracranial germ cell tumors in subjects with Down syndrome.

Pathogenesis of intracranial germ cell tumors reconsidered

OBJECT

To determine the pathogenesis of intracranial germ cell tumors (GCTs), the author studied 153 cases of these tumors encountered through 1994, 62.7% of which showed monotypic histological patterns and 37.3% of which were shown to be mixed tumors.

METHODS

Six patients died soon after admission and underwent autopsy; the other patients underwent surgery followed by radio- and/or chemotherapy. One hundred thirty-four cases were followed through the end of 1997. All patients with a choriocarcinoma died within 1 year. Patients with a yolk sac tumor (endodermal sinus tumor) or an embryonal carcinoma also had poor outcomes. Patients with a mature teratoma had 5- and 10-year survival rates of 93% each. Patients with an immature teratoma had 5- and 10-year survival rates of 86% each, whereas patients who had a teratoma with malignant transformation had a 3-year survival rate of 50%. Patients with a germinoma had a 5-year survival rate of 96% and a 10-year survival rate of 93%. These results may bring into question the validity of the germ cell theory because germinoma, which should be the most undifferentiated tumor according to the theory, was the most benign and choriocarcinoma and yolk sac tumor (endodermal sinus tumor), which should be the most differentiated tumors, were the most malignant according to results obtained during the follow-up study.

CONCLUSIONS

Germ cell tumors other than germinomas may not originate from one single type of cell (primordial germ cells). The embryonic cells of various stages of embryogenesis may perhaps be misplaced in the bilaminar embryonic disc at the time of the primitive streak formation, becoming involved in the stream of lateral mesoderm and carried to the neural plate area to become incorrectly enfolded into the brain at the time of neural tube formation. The author propounds the following hypothesis: tumors composed of cells resembling the cells that appear in the earlier stages of embryogenesis (ontogenesis) are more malignant than those composed of cells resembling the cells that appear in the later stages of embryogenesis.

[Germ-cell tumors of the testis]

Testis tumours constitute only 1% of all male tumours, but are the commonest neoplasia from 20 to 35 years of age. Their relative rarity, the shyness of patients and doctors, and the fact that tumours in general are not common in young adults, all contribute to frequent delays in diagnosis. Fantastic therapeutic advances have been made in the last decades, making long term survival achievable in more than 90% of patients. Nevertheless, the delays in diagnosis lead to an increase in treatment associated morbidity. In this article, the authors present the main aspects of etiopathogenesis, histopathology, diagnosis and treatment of testis tumours.

Germinal cell tumors of the testis in cryptorchids

The medical records of 876 patients with germinal cell tumor of the testis seen at our hospital between 1984 and 1996 were analyzed; 25 (2.85%) were reported to have tumors in undescended testis. Twenty-one patients had unilateral involvement and four had bilateral. Cryptorchidism was corrected ipsilaterally in 7 patients with intrascrotal testicular cancer between 6 and 13 years of age. The primary tumor was in the abdominal testis in 11 patients and in the inguinal canal in 7 (28%) patients. Three patients had persistent Müllerian duct syndrome. One of the three patients with persistent Müllerian duct syndrome also had transverse testicular ectopia. Clinical staging showed 10 stage I, 8 stage IIC, 3 stage III and 4 stage IV. Tumor histologic types on orchidectomy showed seminoma in 20, non-seminoma in 3 and mixed tumors in 2 patients. According to stage and histologic findings all patients were treated with radiotherapy or chemotherapy. Overall, 3 and 5 years survival in seminoma patients was 100% while in non-seminoma and mixed tumor patients was 80% and 60%, respectively. Since orchidopexy offers only limited protection against future malignancy if performed after 2 years of age, the treatment of choice should be orchidectomy. Cryptorchid testes that descended spontaneously or by hormonal therapy should be followed lifelong by testicular ultrasound at least once a year for early detection of cancer. For bilaterally orchidectomised cases administration of androgens is mandatory to prevent sexual dysfunction and hot flushes.

[A case of metastatic testicular tumor in a schizophrenic patient: experience of multidisciplinary treatment at the urology ward]

A 39-year-old man with schizophrenia and suicide attempt was diagnosed with stage IIb testicular tumor. He was initially admitted to the psychiatry ward and underwent high orchiectomy. After schizophrenia became stable by administration of antipsychopathic drugs, he was transferred to the ordinary urology ward and treated with 3 courses of chemotherapy (bleomycin, etoposide, cisplatin) and retroperitoneal lymph noded dissection. The mental status of the patient remained under good control throughout the course of treatment. He has been free of recurrence for 8 months postoperatively. We discussed general medical issues concerning the treatment of malignant diseases in patients with psychosis.

Maternal health and pre- and perinatal characteristics in the etiology of testicular cancer: a prospective population- and register-based study on Norwegian males born between 1967 and 1995

OBJECTIVES

The aim of the present prospective study was to identify possible risk factors of testicular cancer (TC) in relation to gestation and birth.

METHODS

Based on data from compulsory birth and cancer registration in Norway, odds ratios (ORs) of TC were estimated.

RESULTS

Among 868068 males born between 1967 and 1995, 268 cases of germ cancer had developed by June 1996, 32 TCs before 5 years of age and 236 TCs thereafter, 48 cases being seminomas and 220 non-seminomas. There was a tendency of an inverse association between parity and TC. A previous finding from Sweden linking neonatal jaundice to risk of non-seminomas was confirmed (adjusted OR = 2.1, 95 percent confidence interval [CI] = 1.3-6.9). Significant associations were also seen for seminomas and TC diagnosed after 5 years of age. Maternal disease diagnosed before pregnancy increased the risk of TC significantly, particularly in the age group 0-4 years: Adjusted OR = 3.0, CI = 1.4-6.3. Retained placenta was significantly associated with both seminomas and non-seminomas and with TC diagnosed after 5 years of age.

CONCLUSIONS

The findings of this study support the existing hypothesis that pre- and perinatal risk factors are of significance for development of TC in children and in young adults, and for seminomas and non-seminomas. The hypothesis that estrogens are involved in TC development was, among other factors, supported by the association of parity to TC. Additionally, on the basis of findings in maternal diseases and complications to pregnancy, we suggest that immune reactions during foetal life may be of significance for development of TC.